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Controversies in Perioperative Anesthetic Management of the Morbidly Obese: I Am a Surgeon, Why Should I Care?

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Abstract

Over the last four decades, as the rates of obesity have increased, so have the challenges associated with its anesthetic management. In the present review, we discuss perioperative anesthesia management issues that are modifiable by the early involvement of the surgical team. We sum up available evidence or expert opinion on issues like patient positioning, postoperative analgesia, and the effect of continuous positive airway pressure (CPAP) ventilation on surgical anastomosis. We also address established predictors of higher perioperative risk and suggest possible management strategies and concerns of obese patients undergoing same day procedures. Finally, a generalized pharmacological model relevant to altered pharmacokinetics in these patients is presented.

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References

  1. Stefater MA, Wilson-Perez HE, Chambers AP, et al. All bariatric surgeries are not created equal: insights from mechanistic comparisons. Endocr Rev. 2012;33(4):595–622.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  2. Neff K, Olbers T, le Roux C. Bariatric surgery: the challenges with candidate selection, individualizing treatment and clinical outcomes. BMC Med. 2013;11:8.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  3. Encinosa WE, Bernard DM, Du D, et al. Recent improvements in bariatric surgery outcomes. Med Care. 2009;47(5):531–5.

    Article  PubMed  Google Scholar 

  4. Bellamy MC, Margarson MP. Designing intelligent anesthesia for a changing patient demographic: a consensus statement to provide guidance for specialist and non-specialist anesthetists written by members of and endorsed by the Society for Obesity and Bariatric Anaesthesia (SOBA). Perioperative Med. 2013;2(1):12.

    Article  Google Scholar 

  5. Romero-Corral A, Somers VK, Sierra-Johnson J, et al. Accuracy of body mass index to diagnose obesity in the US adult population. Int J Obes (Lond). 2008;32(6):959–66.

    Article  CAS  Google Scholar 

  6. Villamere J, Gebhart A, Vu S, et al. Body mass index is predictive of higher in-hospital mortality in patients undergoing laparoscopic gastric bypass but not laparoscopic sleeve gastrectomy or gastric banding. Am Surg. 2014;80(10):1039–43.

    PubMed  Google Scholar 

  7. Wang S, Majumdar SR, Padwal R. BMI, annual blood pressure measurements, and mortality in patients with obesity and hypertension: a retrospective cohort study. Blood Press Monit. 2014;19.

  8. Valenta I, Dilsizian V, Quercioli A, et al. Impact of obesity and bariatric surgery on metabolism and coronary circulatory function. Curr Cardiol Rep. 2014;16(1):433.

    Article  PubMed  Google Scholar 

  9. Memtsoudis SG, Bombardieri AM, Ma Y, et al. Mortality of patients with respiratory insufficiency and adult respiratory distress syndrome after surgery: the obesity paradox. J Intensive Care Med. 2012;27(5):306–11.

    Article  PubMed  Google Scholar 

  10. Mullen JT, Moorman DW, Davenport DL. The obesity paradox: body mass index and outcomes in patients undergoing nonbariatric general surgery. Ann Surg. 2009;250(1):166–72.

    Article  PubMed  Google Scholar 

  11. WHO | Waist circumference and waist–hip ratio [Internet]. WHO. [cited 2014 Oct 6]. Available from: http://www.who.int/nutrition/publications/obesity/WHO_report_waistcircumference_and_waisthip_ratio/en/

  12. Hu FB. Obesity and mortality: watch your waist, not just your weight. Arch Intern Med. 2007;167(9):875–6.

    Article  PubMed  Google Scholar 

  13. Song X, Jousilahti P, Stehouwer CDA, et al. Comparison of various surrogate obesity indicators as predictors of cardiovascular mortality in four European populations. Eur J Clin Nutr. 2013;67(12):1298–302.

    Article  CAS  PubMed  Google Scholar 

  14. Lee W, Nagubadi S, Kryger MH, et al. Epidemiology of obstructive sleep apnea: a population-based perspective. Expert Rev Respir Med. 2008;2(3):349–64.

    Article  PubMed Central  PubMed  Google Scholar 

  15. Punjabi NM. The epidemiology of adult obstructive sleep apnea. Proc Am Thorac Soc. 2008;5(2):136–43.

    Article  PubMed Central  PubMed  Google Scholar 

  16. Peppard PE, Young T, Barnet JH, et al. Increased prevalence of sleep-disordered breathing in adults. Am J Epidemiol. 2013 Apr 14;kws342.

  17. Wadhwa A, Singh PM, Sinha AC. Airway management in patients with morbid obesity. Int Anesthesiol Clin. 2013;51(3):26–40.

    Article  PubMed  Google Scholar 

  18. Mutter TC, Chateau D, Moffatt M, et al. A matched cohort study of postoperative outcomes in obstructive sleep apnea: could preoperative diagnosis and treatment prevent complications? Anesthesiology. 2014;121(4):707–18.

    Article  PubMed  Google Scholar 

  19. Hallowell PT, Stellato TA, Petrozzi MC, et al. Eliminating respiratory intensive care unit stay after gastric bypass surgery. Surgery. 2007;142(4):608–12. e1.

    Article  PubMed  Google Scholar 

  20. Govindarajan R, Ghosh B, Sathyamoorthy MK, et al. Efficacy of ketorolac in lieu of narcotics in the operative management of laparoscopic surgery for morbid obesity. Surg Obes Relat Dis. 2005;1(6):530–5. discussion 535–6.

    Article  PubMed  Google Scholar 

  21. Kamelgard JI, Kim KA, Atlas G. Combined preemptive and preventive analgesia in morbidly obese patients undergoing open gastric bypass: a pilot study. Surg Obes Relat Dis. 2005;1(1):12–6.

    Article  PubMed  Google Scholar 

  22. Farney RJ, Walker BS, Farney RM, et al. The STOP-bang equivalent model and prediction of severity of obstructive sleep apnea: relation to polysomnographic measurements of the apnea/hypopnea index. J Clin Sleep Med. 2011;7(5):459–65.

    PubMed Central  PubMed  Google Scholar 

  23. Chung F, Yang Y, Liao P. Predictive performance of the STOP-Bang score for identifying obstructive sleep apnea in obese patients. Obes Surg. 2013;23(12):2050–7.

    Article  PubMed  Google Scholar 

  24. Denker MG, Cohen DL. Use of continuous positive airway pressure for sleep apnea in the treatment of hypertension. Curr Opin Nephrol Hypertens. 2014;23(5):462–7.

    Article  PubMed  Google Scholar 

  25. Diogo LN, Monteiro EC. The efficacy of antihypertensive drugs in chronic intermittent hypoxia conditions. Front Physiol. 2014;5:361.

    Article  PubMed Central  PubMed  Google Scholar 

  26. Chen L, Pei J-H, Chen H-M. Effects of continuous positive airway pressure treatment on glycaemic control and insulin sensitivity in patients with obstructive sleep apnoea and type 2 diabetes: a meta-analysis. Arch Med Sci. 2014;10(4):637–42.

    Article  PubMed Central  PubMed  Google Scholar 

  27. Raghuram A, Clay R, Kumbam A, et al. A systematic review of the association between obstructive sleep apnea and ventricular arrhythmias. J Clin Sleep Med. 2014 Sep 19.

  28. Hoyos CM, Sullivan DR, Liu PY. Effect of CPAP on the metabolic syndrome: a randomised sham-controlled study. Thorax. 2013;68(6):588–9.

    Article  CAS  PubMed  Google Scholar 

  29. Xie X, Pan L, Ren D, et al. Effects of continuous positive airway pressure therapy on systemic inflammation in obstructive sleep apnea: a meta-analysis. Sleep Med. 2013;14(11):1139–50.

    Article  PubMed  Google Scholar 

  30. González-Pérez J, Sánchez-Leenheer S, Delgado AR, et al. Clinical impact of a 6-week preoperative very low calorie diet on body weight and liver size in morbidly obese patients. Obes Surg. 2013;23(10):1624–31.

    Article  PubMed  Google Scholar 

  31. Committee on Standards and Practice Parameters, Apfelbaum JL, Connis RT, et al. Practice advisory for preanesthesia evaluation: an updated report by the American society of anesthesiologists task force on preanesthesia evaluation. Anesthesiology. 2012;116(3):522–38.

    Article  Google Scholar 

  32. Wang Y, Yang Y, Liu Y, et al. Evaluation on the accuracy of obese indexes in predicting obstructive sleep apnea-hypopnea syndrome in male adults. Zhonghua Liu Xing Bing Xue Za Zhi. 2007;28(10):1021–5.

    PubMed  Google Scholar 

  33. Rodrigo C. The effects of cigarette smoking on anesthesia. Anesth Prog. 2000;47(4):143–50.

    PubMed Central  CAS  PubMed  Google Scholar 

  34. Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery a report of the American college of cardiology/American heart association task force on practice guidelines. Circulation. 2014;130(24):e278–333.

    Article  PubMed  Google Scholar 

  35. Jämsen E, Nevalainen P, Eskelinen A, et al. Obesity, diabetes, and preoperative hyperglycemia as predictors of periprosthetic joint infection: a single-center analysis of 7181 primary hip and knee replacements for osteoarthritis. J Bone Joint Surg Am. 2012;94(14):e101.

    Article  PubMed  Google Scholar 

  36. Bodnar TW, Gianchandani R. Preprocedure and preoperative management of diabetes mellitus. Postgrad Med. 2014;126(6):73–80.

    Article  PubMed  Google Scholar 

  37. Chiao FB, Resta-Flarer F, Lesser J, et al. Vein visualization: patient characteristic factors and efficacy of a new infrared vein finder technology. Br J Anaesth. 2013;110(6):966–71.

    Article  CAS  PubMed  Google Scholar 

  38. De Jong A, Molinari N, Pouzeratte Y, et al. Difficult intubation in obese patients: incidence, risk factors, and complications in the operating theatre and in intensive care units. Br J Anaesth. 2014;27.

  39. Capella null, Capella null. Is Routine invasive monitoring indicated in surgery for the morbidly obese? Obes Surg. 1996;6(1):50–3.

    Article  Google Scholar 

  40. Pierin AMG, Alavarce DC, Gusmão JL, et al. Blood pressure measurement in obese patients: comparison between upper arm and forearm measurements. Blood Press Monit. 2004;9(3):101–5.

    Article  PubMed  Google Scholar 

  41. Booth RE. Total knee arthroplasty in the obese patient: tips and quips. J Arthroplasty. 2002;17(4 Suppl 1):69–70.

    Article  PubMed  Google Scholar 

  42. Belmont PJ, Goodman GP, Waterman BR, et al. Thirty-day postoperative complications and mortality following total knee arthroplasty: incidence and risk factors among a national sample of 15,321 patients. J Bone Joint Surg Am. 2014;96(1):20–6.

    Article  PubMed  Google Scholar 

  43. Kishore K, Agarwal A. Ultrasound-guided continuous transverse abdominis plane block for abdominal surgery. J Anaesthesiol Clin Pharmacol. 2011;27(3):336–8.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  44. Singh P, Ludwig N, McConachie I, et al. The obese or thin patient. Anesthesia and Perioperative Care of the High-Risk Patient. Third. Cambridge, UK: Cambridge University Press; p. 137–53.

  45. Freeman AL, Pendleton RC, Rondina MT. Prevention of venous thromboembolism in obesity. Expert Rev Cardiovasc Ther. 2010;8(12):1711–21.

    Article  PubMed Central  PubMed  Google Scholar 

  46. Paul DR, Hoyt JL, Boutros AR. Cardiovascular and respiratory changes in response to change of posture in the very obese. Anesthesiology. 1976;45(1):73–8.

    Article  CAS  PubMed  Google Scholar 

  47. Yap JC, Watson RA, Gilbey S, et al. Effects of posture on respiratory mechanics in obesity. J Appl Physiol. 1995;79(4):1199–205.

    CAS  PubMed  Google Scholar 

  48. Perilli V, Sollazzi L, Bozza P, et al. The effects of the reverse trendelenburg position on respiratory mechanics and blood gases in morbidly obese patients during bariatric surgery. Anesth Analg. 2000;91(6):1520–5.

    Article  CAS  PubMed  Google Scholar 

  49. Perilli V, Sollazzi L, Modesti C, et al. Comparison of positive end-expiratory pressure with reverse Trendelenburg position in morbidly obese patients undergoing bariatric surgery: effects on hemodynamics and pulmonary gas exchange. Obes Surg. 2003;13(4):605–9.

    Article  CAS  PubMed  Google Scholar 

  50. Brodsky JB. Positioning the morbidly obese patient for anesthesia. Obes Surg. 2002;12(6):751–8.

    Article  PubMed  Google Scholar 

  51. Okamoto K, Kochi T, Yoshizaki S, et al. oxygenation during one lung ventilation in obese patients. Masui. 1999;48(2):168–71.

    CAS  PubMed  Google Scholar 

  52. Brodsky JB, Wyner J, Ehrenwerth J, et al. One-lung anesthesia in morbidly obese patients. Anesthesiology. 1982;57(2):132–4.

    Article  CAS  PubMed  Google Scholar 

  53. De Jong A, Molinari N, Sebbane M, et al. Feasibility and effectiveness of prone position in morbidly obese patients with ARDS: a case-control clinical study. Chest. 2013;143(6):1554–61.

    Article  PubMed  Google Scholar 

  54. Mechanick JI, Kushner RF, Sugerman HJ, et al. American association of clinical endocrinologists, the obesity society, and American society for metabolic & bariatric surgery medical guidelines for clinical practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient. Obesity (Silver Spring). 2009;1:S1–70. v.

    Google Scholar 

  55. SAGES Guidelines Committee. SAGES guideline for clinical application of laparoscopic bariatric surgery. Surg Obes Relat Dis. 2009;5(3):387–405.

    Article  Google Scholar 

  56. Brethauer SA, Chand B, Schauer PR. Risks and benefits of bariatric surgery: current evidence. Cleve Clin J Med. 2006;73(11):993–1007.

    Article  PubMed  Google Scholar 

  57. Fortier J, Chung F, Su J. Unanticipated admission after ambulatory surgery–a prospective study. Can J Anaesth. 1998;45(7):612–9.

    Article  CAS  PubMed  Google Scholar 

  58. Joshi GP, Ahmad S, Riad W, et al. Selection of obese patients undergoing ambulatory surgery: a systematic review of the literature. Anesth Analg. 2013;117(5):1082–91.

    Article  PubMed  Google Scholar 

  59. Hofer RE, Kai T, Decker PA, et al. Obesity as a risk factor for unanticipated admissions after ambulatory surgery. Mayo Clin Proc. 2008;83(8):908–16.

    Article  PubMed  Google Scholar 

  60. Wani S, Azar R, Hovis CE, et al. Obesity as a risk factor for sedation-related complications during propofol-mediated sedation for advanced endoscopic procedures. Gastrointest Endosc. 2011;74(6):1238–47.

    Article  PubMed Central  PubMed  Google Scholar 

  61. Goudra BG, Singh PM, Penugonda LC, et al. Significantly reduced hypoxemic events in morbidly obese patients undergoing gastrointestinal endoscopy: predictors and practice effect. J Anaesthesiol Clin Pharmacol. 2014;30(1):71–7.

    Article  PubMed Central  PubMed  Google Scholar 

  62. Ramirez A, Lalor PF, Szomstein S, et al. Continuous positive airway pressure in immediate postoperative period after laparoscopic Roux-en-Y gastric bypass: is it safe? Surg Obes Relat Dis. 2009;5(5):544–6.

    Article  PubMed  Google Scholar 

  63. Jensen C, Tejirian T, Lewis C, et al. Postoperative CPAP and BiPAP use can be safely omitted after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2008;4(4):512–4.

    Article  PubMed  Google Scholar 

  64. Ahmad S, Nagle A, McCarthy RJ, et al. Postoperative hypoxemia in morbidly obese patients with and without obstructive sleep apnea undergoing laparoscopic bariatric surgery. Anesth Analg. 2008;107(1):138–43.

    Article  PubMed  Google Scholar 

  65. Neligan PJ, Malhotra G, Fraser M, et al. Continuous positive airway pressure via the Boussignac system immediately after extubation improves lung function in morbidly obese patients with obstructive sleep apnea undergoing laparoscopic bariatric surgery. Anesthesiology. 2009;110(4):878–84.

    Article  PubMed  Google Scholar 

  66. Basoglu OK, Midilli M, Midilli R, et al. Adherence to continuous positive airway pressure therapy in obstructive sleep apnea syndrome: effect of visual education. Sleep Breath. 2012;16(4):1193–200.

    Article  PubMed  Google Scholar 

  67. Richards GN, Cistulli PA, Ungar RG, et al. Mouth leak with nasal continuous positive airway pressure increases nasal airway resistance. Am J Respir Crit Care Med. 1996;154(1):182–6.

    Article  CAS  PubMed  Google Scholar 

  68. Gaszynski T, Tokarz A, Piotrowski D, et al. Boussignac CPAP in the postoperative period in morbidly obese patients. Obes Surg. 2007;17(4):452–6.

    Article  PubMed  Google Scholar 

  69. Orvar KB, Gregersen H, Christensen J. Biomechanical characteristics of the human esophagus. Dig Dis Sci. 1993;38(2):197–205.

    Article  CAS  PubMed  Google Scholar 

  70. Harding SM. CPAP-related aerophagia: awareness first! J Clin Sleep Med. 2013;9(1):19–20.

    PubMed Central  PubMed  Google Scholar 

  71. Alvarez A, Singh PM, Sinha AC. Postoperative analgesia in morbid obesity. Obes Surg. 2014;24(4):652–9.

    Article  PubMed  Google Scholar 

  72. Mogri M, Khan MIA, Grant BJB, et al. Central sleep apnea induced by acute ingestion of opioids. Chest. 2008;133(6):1484–8.

    Article  PubMed  Google Scholar 

  73. Ekström MP, Bornefalk-Hermansson A, Abernethy AP, et al. Safety of benzodiazepines and opioids in very severe respiratory disease: national prospective study. BMJ. 2014;348:g445.

    Article  PubMed Central  PubMed  Google Scholar 

  74. Alvarez A, Singh PM, Sinha AC. Tissue oxygenation in morbid obesity—the physiological and clinical perspective. Trends Anaesthesia Crit Care. 2013;3(6):310–5.

    Article  Google Scholar 

  75. Sinclair RCF, Faleiro RJ. Delayed recovery of consciousness after anaesthesia. Contin Educ Anaesth Crit Care Pain. 2006;6(3):114–8.

    Article  Google Scholar 

  76. Ibrahim MS, Khan MA, Nizam I, et al. Peri-operative interventions producing better functional outcomes and enhanced recovery following total hip and knee arthroplasty: an evidence-based review. BMC Med. 2013;11:37.

    Article  PubMed Central  PubMed  Google Scholar 

  77. Sinha AC, Singh PM, Williams NW, et al. Aprepitant’s prophylactic efficacy in decreasing postoperative nausea and vomiting in morbidly obese patients undergoing bariatric surgery. Obes Surg. 2014;24(2):225–31.

    Article  PubMed  Google Scholar 

  78. Singh PM, Wadhwa A. Multimodal analgesia in patients with morbid obesity. Bariatric Times. 2013;10(11):24–9.

    Google Scholar 

  79. Brodsky JB, Lemmens HJM. Update on local and regional anesthesia in obesity. Acta Anaesthesiol Belg. 2009;60(3):181–3.

    CAS  PubMed  Google Scholar 

  80. Feld JM, Laurito CE, Beckerman M, et al. Non-opioid analgesia improves pain relief and decreases sedation after gastric bypass surgery. Can J Anaesth. 2003;50(4):336–41.

    Article  PubMed  Google Scholar 

  81. Sollazzi L, Modesti C, Vitale F, et al. Preinductive use of clonidine and ketamine improves recovery and reduces postoperative pain after bariatric surgery. Surg Obes Relat Dis. 2009;5(1):67–71.

    Article  PubMed  Google Scholar 

  82. Kaur M, Singh P. Current role of dexmedetomidine in clinical anesthesia and intensive care. Anesthesia: Essays Res. 2011;5(2):128.

    Google Scholar 

  83. Schumann R, Jones SB, Cooper B, et al. Update on best practice recommendations for anesthetic perioperative care and pain management in weight loss surgery, 2004-2007. Obesity (Silver Spring). 2009;17(5):889–94.

    Article  Google Scholar 

  84. Schumann R, Shikora S, Weiss JM, et al. A comparison of multimodal perioperative analgesia to epidural pain management after gastric bypass surgery. Anesth Analg. 2003;96(2):469–74. table of contents.

    CAS  PubMed  Google Scholar 

  85. Barbalho-Moulim MC, Miguel GPS, Forti EMP, et al. Effects of preoperative inspiratory muscle training in obese women undergoing open bariatric surgery: respiratory muscle strength, lung volumes, and diaphragmatic excursion. Clinics. 2011;66(10):1721–7.

    Article  PubMed Central  PubMed  Google Scholar 

  86. Forbes GB, Welle SL. Lean body mass in obesity. Int J Obes. 1983;7(2):99–107.

    CAS  PubMed  Google Scholar 

  87. Hume R. Prediction of lean body mass from height and weight. J Clin Pathol. 1966;19(4):389–91.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  88. Sandowski SA. What is the ideal body weight? Fam Pract. 2000;17(4):348–51.

    Article  CAS  PubMed  Google Scholar 

  89. Sapala JA, Wood MH, Schuhknecht MP, et al. Fatal pulmonary embolism after bariatric operations for morbid obesity: a 24-year retrospective analysis. Obes Surg. 2003;13(6):819–25.

    Article  PubMed  Google Scholar 

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None for both the authors (Dr Ashish Sinha and Dr Preet Mohinder Singh).

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Authors and Affiliations

  1. Anesthesiology and Perioperative Medicine, Drexel University College of Medicine, Philadelphia, PA, USA

    Ashish C. Sinha

  2. Department of Anesthesia, All India Institute of Medical Sciences, New Delhi, India

    Preet Mohinder Singh

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  1. Ashish C. Sinha
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  2. Preet Mohinder Singh
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Correspondence to Ashish C. Sinha.

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Sinha, A.C., Singh, P.M. Controversies in Perioperative Anesthetic Management of the Morbidly Obese: I Am a Surgeon, Why Should I Care?. OBES SURG 25, 879–887 (2015). https://doi.org/10.1007/s11695-015-1635-5

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